To the Editor:
We read with interest the recent manuscript by Thevenot et al. [
[1]
] which adds data to the debate on the potential beneficial effect of albumin administration during episodes of infections other than spontaneous bacterial peritonitis (SBP) in cirrhotic patients [2
, 3
, 4
].In this multicentre study, 193 cirrhotic patients with infections other than SBP, were randomly assigned to receive albumin infusion or no treatment in addition to antibiotics. The primary outcomes were renal failure and mortality rates. The study failed to show any beneficial effect on these outcomes, although albumin infusion delayed the onset of renal failure. However, in our opinion, some bias could have influenced the results. First, the prevalence of ascites was significantly higher in the patients randomized to albumin and antibiotics than in the patients assuming antibiotics alone (75.8 vs. 59.6%; p = 0.017). The development of infection and the consequent increase in vasodilatation may have influenced the rate of renal failure and prognosis of the former group differently from the control group in which the number of patients with ascites was lower. Second, the success or failure of antibiotic therapies were not analyzed and, as we know, the course of infections is a further important parameter for the prognosis of cirrhotic patients [
5
, 6
]. Third, as also discussed by the authors, many violations occurred in the protocol and 17 patients in the control group also received albumin for large volume paracentesis during the first week.Thus, in our opinion, the results of the present study should not discourage further investigations in cirrhotic patients with infections also considering the wide range of potential benefits of albumin administration in this setting (antioxidant function, immunomodulation, anti-inflammatory activity and transport of many endogenous and exogenous substances), in addition to its well-known effect as plasma expander [
[7]
]. Among these additional properties, in particular, the effect of the albumin infusion during the therapy with moderately/highly protein-bound antibiotics should also be evaluated, considering the relevant role of hypoalbuminemia on the pharmacokinetics of these antibiotics [[8]
].Conflict of interest
The authors declared that they do not have anything to disclose regarding funding or conflict of interest with respect to this manuscript.
References
- Effect of albumin in cirrhotic patients with infections other than spontaneous bacterial peritonitis: a randomized trial.J Hepatol. 2015; 62: 822-830
- Albumin for bacterial infections other than spontaneous bacterial peritonitis in cirrhosis. A randomized, controlled study.J Hepatol. 2012; 57: 759-765
- Effect of albumin on survival in septic cirrhotic patients other than spontaneous bacterial peritonitis. The question remains open.J Hepatol. 2013; 58: 638-639
- Reply to: “Effect of albumin on survival in septic cirrhotic patients other than spontaneous bacterial peritonitis. The question remains open”.J Hepatol. 2013; 58: 640
- Infections in patients with cirrhosis increase mortality four-fold and should be used in determining prognosis.Gastroenterology. 2010; 139: 1246-1256
- Cirrhotic patients are at risk for health care-associated bacterial infections.Clin Gastroenterol Hepatol. 2010; 8: 979-985
- Clinical indications for the albumin use: still a controversial issue.Eur J Intern Med. 2013; 24: 721-728
- Individualised antibiotic dosing for patients who are critically ill: challenges and potential solutions.Lancet Infect Dis. 2014; 14: 498-509
Article info
Publication history
Published online: May 16, 2015
Accepted:
April 11,
2015
Received in revised form:
April 9,
2015
Received:
March 23,
2015
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© 2015 European Association for the Study of the Liver. Published by Elsevier B.V.
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